Chapter 4 – Communication Stations

Introduction

The different scenarios that can be covered in a communication station are vast.

Common themes revolve around: conflict resolution; difficult referral/conversation and breaking bad news.

Other scenarios that have come up include obtaining consent; managing a patient with a needle stick; the CDU ward round; a major incident and departmental flow.

Pay attention to

  • Body language – what messages are you sending to your patient and are they sending to you
  • Silence is golden (but feels uncomfortable – count to 10 before speaking after breaking bad news)
  • Let the patient speak
  • Involve the patient/other specialty  in decision making
  • Don’t make promises you can’t keep
  • Try to remain calm

Common Scenarios

I would ensure: 

  • Any immediate patient safety concerns are addressed.
  • The department is safe (handed over to a colleague). 
  • Information gathering had occurred (eg, review of notes, ideally see patient yourself).
  • Quiet, private location. 
  • Senior member of nursing staff present.

“Hello, my name is Dr Smith, I am one of the Senior Doctors working in the Emergency Department today.”

“Can I just confirm your name and whose relative you are?”

“I have been told you have concerns you would like to discuss, shall we move to somewhere more private to do this?”

“Before we start, shall we sit down, and is there anything I can get you? Do you need any pain relief or a drink (situation dependent)?”

“Please can you tell me what you are concerned and unhappy about?”

“Thank you for informing me of this.”

“Let me just summarise what you have said so I can ensure I understand your concerns.”

“I am really sorry that you/your relative feel(s) like this, and I want to do all I can to improve things going forward.

Firstly: I would like to: 

ANGRY PATIENT: “listen to your history and examine you. We can decide on a plan and any investigations together.”

ANGRY RELATIVE: “go and see your relative and ensure they are now comfortable. I will then take a history and examine them and look at any results so we can make a plan together.

“Does that sound reasonable to you?”

Secondly:

“I want to try and reassure you that we take concerns very seriously and this incident/issue will be looked at formally. I will complete an incident form and ensure the Consultant/Matron are aware.”

“We always ensure we learn from any incident to try and ensure it doesn’t happen again. Usually this is by speaking to those directly involved and wider departmental awareness through teaching”

“For the time being have we managed to address your concerns?”

“Is there anything else you want to discuss?”

“If now or later you want to raise this further  you can contact the Patient Advice Liaison Service, they can give you advice about how to make a formal complaint if you so wish. I can go any get you their contact details now if you would like.”

“Thank you for raising this issue with me.”

Complaints procedure

It is unlikely that you will need to know much more than the existance of PALS and that a complaints process exists, but this is included here for interest.

If there is an immediate concern you need to decide whether the complaint meets the SIRI (serious incident requiring investigation) threshold. If it doesn’t complaints are generally managed and escalated as follows:

  1. PALS if immediate resolution is possible/likely.
  2. Referral to the complaints team. This must be acknowledged within three days and a resolution meeting offered.
  3. A response* should be received within 30 days if not complex.
  4. Final approval of the response comes from the CEO.
  5. If the complainant is not satisfied, they can make a referral to the Parliamentary Health and Service Ombudsman.

*The response process involves an investigation, a draft response which is sent to the divisional nurse and allied HCP director, and a final response being sent to the CEO for them to approve. 

Serious Events Framework

  • Any untoward medical occurrence that results in death/life threat/prolonged stay
  • Report on event within 2 days
  • Initial review within 3 days
  • Investigation & report with RCA (root cause analysis) within 60 days
  • Commissioner review within 20 days of receipt of report

Duty of Candour

Example scenarios

  • Missed fracture/diagnosis management
  • Parents/caregivers or patient requesting CT head post minor head injury

I would ensure: 

  • Any immediate patient safety concerns were addressed.
  • The department is safe (handed over to a colleague). 
  • Information gathering had occurred (eg, review of notes, ideally see patient yourself if a previous attempt to refer has not been successful).
  • Quiet, private location. 
  • Senior member of nursing staff present.

“Hello, my name is Dr Smith, I am one of the Senior Doctors working in the Emergency Department today.”

“Can I just confirm your name and whose relative you are?”

“I have been told you have concerns you would like to discuss, shall we move to somewhere more private to do this?”

“Before we start, shall we sit down, and is there anything I can get you? Do you need any pain relief or a drink (situation dependent)?”

“Please can you tell me what you are concerned and unhappy about?”

“Thank you for informing me of this.”

“Let me just summarise what you have said so I can ensure I understand your concerns.”

“I am really sorry that you/your relative feel(s) like this, and I want to do all I can to improve things going forward.

“Perhaps I can try and explain why I feel we should/should not be doing this.”

Consider the following where appropriate:

  • Acknowledge concerns/frustrations
  • Explain reasons of doing/not doing something
  • Explore particular concerns
  • Offer a second opinion
  • If a condition: time frame, how to manage
  • Safety net
  • Try and agree plan

Just to summarise, 

“Your concerns were…”

“We have discussed that…”

“Our plan is… including safety net and online resources”

“Do you feel I have addressed your concerns, or do you have any further questions?”

Example scenarios

  • Request for antimicrobials
  • Tick bite, requesting antibiotics
  • Refusing tetanus
  • Giving DVLA advice

I would ensure: 

  • Any immediate patient safety concerns were addressed.
  • The department is safe (handed over to a colleague). 
  • Information gathering had occurred (eg, review of notes, ideally see patient yourself if a previous attempt to refer has not been successful).
  • Quiet, private location.
  • Senior member of nursing staff present.

“Hello, my name is Dr Smith, I am one of ED Registrars.”

“Are you the SpR/Consultant? Great, can I take your name and grade please?”

“I’m sorry to bother you, I hear you are really busy, but I need to discuss a case, are you free to talk?”

Use SBAR (Situation; Background; Assessment; Recommendations):

S: I have Mr Jones with…

B: The background is this…

A: Having just seen the patient I am concerned that…

R: Which is why I feel referral under your team is appropriate

  • Listen to their concerns

Apologise: for anything brought up. For example “I’m sorry if you have experienced poor referrals previously”

Acknowledge their issues: For example “I appreciate you are busy…”

BUT I am concerned about… I don’t think the patient is safe to discharge/admit to CDU etc, and I really would appreciate your input.

Is there anything I can do from our end which would be helpful to have prior to you seeing this patient? E.g. CT head, MRI

Successful:

“Ok many thanks…”

“Do you have a rough time frame for when you may be able to make it down?”

Unsuccessful:

“I don’t think we are making progress here, what i’ll do is I will chat to my Consultant and ask them to ring either you or your Consultant directly, does that sound reasonable?”

Thank you for your time.

I would then document the outcome and time of referral in notes.

Example scenarios

  • Request for antimicrobials
  • Tick bite; requesting antibiotics
  • Refusing tetanus
  • Giving DVLA advice

I would ensure I had:

  • ensure the department is safe and handed over control of the department to a senior. 
  • bleep/phone off.
  • read the patient’s notes.
  • understood diagnosis, immediate and longer term management.
  • member of nursing staff present to support patient privacy.

“Hello my name is Dr Smith, I am one of the senior ED doctors working today.”

“Can you confirm for me your name and date of birth please?”

“Are you comfortable? Do you need any pain killers?”

“I have come to talk to you about what’s brought you into hospital and what we think is going on. Would that be ok with you?”

“Do you want someone else with you?”

“Can you briefly tell me what’s brought you to hospital?”

“Do you have any ideas about what is going on?”

“We think you have X.”

“Do you have much of an idea of what that is?” If no: brief summary

“We are treating X now and this will involve Y”

“It is something that can be managed really well with support.”

“This is a lot to take in, do you have anything in particular you want me to talk to you about?”

  • Affect on life
  • Resources 
  • Lifestyle changes (ETOH; smoking; drugs; weight; etc)

“Do you understand what I have told you?”

“Anything you want me to clarify?”

“If being admitted, the X team will be able to go over things in more detail?”

“I have some written information and online resources to give to you.”

“Do you have any other questions?”

Paed/young adult: “do you want me to talk to your parents/carers?”

Example scenarios

  • Anaphylaxis
  • Type 1 Diabetes
  • Atrial fibrillation
  • Malignancy

I would ensure I had:

  • ensure department is safe – handed over control of department to a senior. 
  • bleep/phone off.
  • fully aware of the details of the patient’s case.
  • member of nursing staff present to support them.

“Hello my name is Dr Smith, I am one of the senior Emergency Doctors working today.”

Can I just confirm your name;  whose relative you are and your relationship to them? May I call you…”

Is there any one else coming or anyone else you want with you?

Before we start can I offer you a drink or anything else?

“I’m really sorry you are here today. What is your understanding of the events that brought your loved one to hospital today?

“That is correct. Since she/he has been with us this is what has happened.”

“I am really sorry, but I have some dreadful news to tell you.”

Situation dependent:

“Mr X has died.”

“After discussion with (for example) the brain surgeons; given the extent of the injury, they do not feel this injury is survivable and your relative, NAME will die.”

SILENCE – count to 10

“Do you understand what I have said?”

Count to 10

“I can’t imagine how hard this news is to take in. Do you have an immediate questions for me?” 

(offer to show any results or imaging that may be available)

“Is there anyone I can contact for you?”

Would you like any religious representation?

“Would you like to see your Mr X?” If yes comment on what they will look like.

“I can’t imagine how awful all this is, but do you know if Mr X wanted to be considered for organ donation?

“What I will do is give you some time now.”

“Our nurse X is here to stay with you. They will go over what will need to happen from now, but only when you are ready.”

“I am really so sorry for your loss. I am here if you think of any questions, no matter how small please let the nurse know and I’ll come back. My name is Trudie Smith and I will be here all evening.”

Example scenarios

Other Scenarios

These stations are focused around ensuring you fulfillful the seven principles of decision making and consent as laid out by the General Medical Council. 

To demonstrate this any procedure or treatment you would recommend to a patient could be used, an example would be obatining consent for intravenous cannulation.

“Hello, my name is  Dr Smith, I am one of the Senior Emergency Doctors working in the Emergency Department today

“Can you confirm your name and date of birth please?”

“How is your pain currently? Do you need more pain relief?”

“What’s your understanding of why I am here and what having a cannula involves?”

“We need to out in a cannula to take some blood tests and give you some treatment into your vein.”

“This will involve me putting a tourniquet arounbd your arm to make the veins larger, cleaning the skin and then inserting the cannula”

“This is a very safe procedure, but it can be a bit sore whilst the cannula is being inserted,”

“Do you have any questions?”



Cite this article as: Iain Beardsell, "Chapter 4 – Communication Stations," in St.Emlyn's, April 30, 2021, https://www.stemlynsblog.org/chapter-4-mla-communication-stations/.